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- Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions∗ ()
- ↵∗Address correspondence to:
Spencer B. King III, MD, Saint Joseph's Heart and Vascular Institute, 5665 Peachtree Dunwoody Road NE, Atlanta, Georgia 30342
The Transcatheter Cardiovascular Therapeutics (TCT) meeting has just wrapped up, and it will be remembered not so much for scientific breakthroughs but for the extensive reflection on the developments of the specialty of interventional cardiology. Because this was the 25th anniversary of the TCT meeting, there were numerous presentations and panels involving us old guys (some would say “old f—s”) who have been around for the past 30-plus years. It is said that we should study history so as not to risk repeating it. As I listened to my colleagues expound and perhaps “expand” on tales of the early days, I could detect a sense of nostalgia, but no one would want to repeat the tribulations of the days of angioplasty before stent implantation. It is instructive for the younger practitioners of our profession to hear that stent placement transformed coronary interventions not just because it reduced restenosis. This was, of course, a frequent occurrence but not such a severe problem after balloon angioplasty. No, the transformation was primarily because it eliminated the dreaded acute occlusion of the artery leading to middle-of-the-night calls back to the catheterization lab or to emergency surgery.
To celebrate the 25 years of TCT, the organizers produced a compelling opening ceremony. It focused on the birth of interventional cardiology and the father of the subspecialty, Andreas Gruentzig. Marty Leon and Gregg Stone conceived the idea of bringing together many of the early contributors and, from old film footage, compiled an emotional video presentation highlighting the birth and beginnings. Marty asked me to invite some of Andreas's family, and we were honored to have his first wife, Michaela, and his 2 daughters come with Gail and me to San Francisco. When Sonja, a professional actress in Berlin, responded to the presentation of the Lifetime Achievement Award posthumously to her father, she said, “Hello, my name is Sonja Gruentzig, and I would like to introduce myself as the twin of the balloon catheter. For as my mother was pregnant with me, my father was pregnant with the balloon catheter. We both hatched in the same hospital in Zurich, and were even brought up at the same kitchen table. So as you may see, we both have thrived and matured over the past 37 years. My mother, Michaela, my sister, Katrin, and I want to thank you for your kind invitation to San Francisco and are honored to receive the award in the name of Andreas Gruentzig.”
The family members who are not bombarded with angioplasty history in Zurich or Berlin were truly touched by the outpouring of gratitude that many expressed for Andreas's seminal contributions to so many lives, be they patients or practitioners.
Somewhat forgotten in the fog of history is how insightful Andreas was about future developments in endovascular therapy. At TCT, stories were told about how he experimented with plaque-removing methods even before the balloon, his opinion of early versions of the stent, and his prediction of a catheter-delivered aortic valve. But the history lessons did not stop with Gruentzig or the early developers of many devices, or the expansion of interventions to more complex anatomy and clinical presentations, especially acute myocardial infarction and the now rapidly growing attack on structural heart disease. There were stories of technical developments, patent fights won and lost, and many personal recollections, in the formal sessions and afterward. There were also a number of clinical trials reported, and as with other recent meetings, many of them seemed to offer negative or neutral results. More interesting were the reports of new technology or variations in current devices aimed at solving some of the current problems of our subspecialty. In some of these, I see a need to revisit our history to learn about what worked and what did not. One area in which we may be headed back to the future is obstructive coronary artery disease, the first frontier for interventional cardiology. The saga of the balloon evolving to the stent and then to the drug-eluting stent is well known. Now we may be heading toward eliminating the stent and returning to a healed artery, with no residual foreign body. The concept of biodegradable stents is so seductive that I learned that some operators in Germany are now using the bioabsorbable scaffold in 90% of patients. Of course, we have no evidence that it is better or worse than drug-eluting metal stents, but this direction, as well as drug-eluting balloons, without any scaffold, and perhaps other methods to modify the healing process may bring us back to what Gruentzig tried the first time around. Without evidence of how the healing of dilated coronary obstructions would work out, balloon dilation was developed, opening the obstruction and then letting nature take its course as the “wound” healed. Many times it even healed open.
Bernie Meier recounted the story of Mr. Bachman, the first angioplasty patient. After Gruentzig opened the artery, the angina was completely relieved. Ten years later, at a 1987 Emory demonstration course, I performed coronary arteriography on Mr. Bachman and found wide patency of the healed left anterior descending coronary artery. In 2000, he reported some symptoms, and Bernie performed another catheterization. Even though the artery was open, recurrent symptoms caused Mr. Bachman to press the issue, resulting in another catheterization, with ambiguous angiographic results. Bachman insisted that he wanted a stent and was sure that this was now needed, as he had followed the evolution of the specialty and knew that he had undergone only balloon angioplasty. The stent was implanted; however, 3 months later, Bachman stated that he now had clear-cut effort angina as bad as he had initially in 1977. Repeat catheterization showed severe restenosis, which Bernie treated with balloon angioplasty, and Mr. Bachman has remained asymptomatic ever since. A take-home message could be that balloon angioplasty worked for 23 years, bare-metal stenting worked for 3 months, and repeat balloon angioplasty has now worked for another 13 years. As amusing as this is, we do not draw this conclusion, but neither should we blindly accept that the current technologies are the only and ultimate solutions. Remembering lessons of the past may enable more progress in the future.
- American College of Cardiology Foundation